Cal. Code Regs. tit. 10 § 2220.52

Current through Register 2024 Notice Reg. No. 50, December 13, 2024

Section 2220.52 - General Policy Provisions

The following shall be applicable to "Medicare Supplement Coverage" and shall be in addition to the requirements of Article 1.5, above. These are minimum standards and do not preclude the inclusion of additional benefits in such coverages:

(a) Pre-existing condition limitations shall not exclude coverage for more than six months after the effective date of coverage under the policy for a condition for which medical advice was given or treatment was recommended by or received from a physician within six (6) months before the effect date of the coverage;

(b) The term "Medicare benefit period" shall mean the unit of time used in the Medicare program to measure use of services and availability of benefits under Part A Medicare hospital insurance;

(c) The term "Medicare eligible expenses" shall mean health care expenses of the kinds covered by Medicare, to the extent recognized as reasonable by Medicare. Payment of benefits by insurers for Medicare eligible expenses may be conditioned upon the same or less restrictive payment conditions, including determinations of medical necessity as are applicable to Medicare claims;

(d) The term "Physician" shall mean a licensed practitioner of the healing arts, practicing within the scope of the practicioner's license. It includes all practitioners described in Insurance Code Section 10176.

(e) The term "nurse" shall mean a registered nurse (R.N.) or a licensed vocational nurse (L.V.N.).

(f) The term "Medicare" shall mean the Health Insurance for the Aged Act, Title XVIII of the Social Security Amendments of 1965 as then constituted or later amended.

(g) The terms "Medicare Supplement," "Medigap" and words of similar import shall not be used to describe a policy unless the policy is issued in compliance with this Article.

(h) Coverage, when issued, shall not be subject to any exclusions, limitations, or reductions (other than as permitted in this Article and other applicable laws and regulations) which are inconsistent with the exclusions, limitations, or reductions permissible under Medicare, other than a provision that coverage is not provided for any expenses to the extent of any benefit available to the insured person under Medicare.

(i) Coverage shall not idemnify against losses resulting from sickness on a different basis than losses resulting from accidents;

(j) Coverage shall provide that benefits designed to cover cost sharing amounts under Medicare will be changed automatically to coincide with any changes in the applicable Medicare deductible amount and co-payment percentage factors; and

(k) Policies providing convalescent or extended care benefits shall not condition such benefits upon admission to the convalescent or extended care facility within a period of less than fourteen (14) days after discharge from the hospital, nor shall they require a hospital confinement exceeding three (3) days.

Cal. Code Regs. Tit. 10, § 2220.52

1. Change without regulatory effect amending subsection (d) filed 7-14-2021 pursuant to section 100, title 1, California Code of Regulations (Register 2021, No. 29). Filing deadline specified in Government Code section 11349.3(a) extended 60 calendar days pursuant to Executive Order N-40-20.

Note: Authority cited: Sections 10291.5 (c) and 10195 (5) (b), Insurance Code. Reference: Section 10291.5(b) (7), Insurance Code.